Stage One – Understanding breastfeeding as a target behaviour
Step 1 – How breastfeeding was defined in behavioural terms
Data supplied by Best Beginnings showed that breastfeeding in behavioural terms was defined in behavioural terms - mothers using the app aged under 25 years, exclusively breastfeeding in every setting, starting within one hour after birth to six months of age.
Step 2 – How breastfeeding behaviours were selected
Best Beginnings defined the key issues in behavioural terms, selecting and then specifying target behaviours and then identifying what needed to change. The evidence reviewed by the research team that supported their analysis included:
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The Infant Feeding Survey (2010) (5)
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World Health Organization (WHO) Global Strategy for Infant and Young Child Feeding (Breastfeeding Manifesto) (15)
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Tackling health inequalities in infant and maternal health outcomes (16)
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Focus On: A Proportionate Approach to Priority Populations (17)
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Fair Society, Healthy Lives – Strategic Review of Health Inequalities in England post 2010 (18)
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The Foundation Years: preventing poor children becoming poor adults (19)
Our research team found that this literature supported the need for interventions to support women in their homes and communities through health services.
Best Beginnings had undertaken extensive consultation with stakeholders; implementers, funders and users. These include the funders and targeted users i.e. the UK Department of Health, UNICEF and women and their families. A strength of their process was that Best Beginnings worked with experienced market researchers. This was key to engaging with women and health care professionals. Documentation provided by Best Beginnings confirmed that a multidisciplinary team approach was adopted in the creation of the steering committee.
Seven target behaviours were found as a priority identified by Best Beginnings with regard to breastfeeding:
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Increasing mothers’ intentions to breastfeed
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Giving advice on commencing breastfeeding
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Giving information on correct positioning and attachment for breastfeeding
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Knowing how to express breast milk
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Knowing what is normal in the first few months of breastfeeding
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Knowing how to overcome breastfeeding challenges
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Planning to breastfeeding for six months or more
Step 3 – How target breastfeeding behaviours were specified
Breastfeeding behaviours were identified from data supplied by Best Beginnings. These were described in relation to: who, what, when, where, how often and with whom. Best Beginnings showed that they utilised mixed methods techniques to better understand the barriers and enablers affecting inequity, disparity and intergenerational disadvantage (Additional file 2). Health care professionals, parents and families were engaged as co-creators at all stages and were instrumental in app development, implementation, evaluation and promotion (20–24). Best Beginnings have followed best practice for selecting breastfeeding as a specific target behaviour and demonstrated a thorough understanding of the context.
Step 4 – Changes needed to support breastfeeding behaviours
Best Beginnings explored breastfeeding in terms of theoretical constructs that could be targeted by public health strategies to aid capability, opportunity and motivation. The review team examined reports, data and evaluations (Additional file 1) and found that a mixed methods approcah had informed the development and embedding process. Their approach consisted of focus groups, workshops, semi-structured interviews and surveys conducted with mothers, partners, midwives, nurses, doctors and academics. The data collected assisted Best Beginnings to identify both modifiable behavioural and non-modifiable behavioural barriers and enablers that needed to be addressed in the intervention elements. The COM-B model was used by the research team to understand breastfeeding in the context in which it occurs in.
Physical And Psychological Capability
Breastfeeding skill development was identified as a key enabler for both physical and psychological capability. Peer and clinical support, demonstrations, practice and feedback were identified as important to empower women to breastfeed. Best Beginnings had explored social norms, peer influence and the value of social support in sustaining breastfeeding. For example, women were asked to discuss breastfeeding in the context of their roles in their families, the presence or absence of support, the influences of cultural values, the impact of migration, isolation and loneliness. Percieved barriers such as difficulties positioning and attaching, low milk production (physical capability) and fear of failure, anxiety/depression (psychological capability) were identified as needing to be addressed by the intervention functions.
Physical And Social Opportunity
Support was identified as the primary enabler for both physical and social opportunity to breastfeed. Clinical/specialist, peer, community and technology support (apps, social media, online resources) were documented as facilitators for breastfeeding. Best Beginnings sought to understand environmental factors that may help, interfere or prevent breastfeeding efforts. Economic barriers and physical environment were discussed and several themes related to challenges in finding a way to initiate and maintain breastfeeding behaviours in the context of their roles as employees, mothers and partners. These barriers reported are consistent with reports in the literature particularly among women who describe a variety of challenges to breastfeeding such as fatique and infant/childcare demands (9).
Reflective And Automatic Motivation
Reflective motivation was identified as being related to decision making to breastfeed. The research team found that breastfeeding motivation is best facilitated by early planning, goal setting and positive belief reinforcement. Peer support normalises the challenges of breastfeeding and encourages self-determination. Support was documented as crucial to help alleviate negative thoughts or low confidence. Self-efficacy to change beliefs and habits and low health literacy barriers were explored to assess the ability of individuals to act on health advice and planned care and to uncover cultural specific values that may improve interventions in specific target groups. All of these barriers have been shown to have an impact on interventions that aim to improve a woman’s ability to adopt healthy behaviours (1, 3).
After mapping the provided documentation, an in-depth analysis was conducted on the app content. The content of videos and text related to breastfeeding was catogorised using the COM-B model. A total of 39 videos, 8 glossary words (‘What does that mean?) and 20 responses to breastfeeding questions (‘Ask me’) were examined in view of which intervention categories were used (Table 2).
Stage Two – Identifying how intervention functions were used
Step 5 – The intervention functions that were used
The middle layer of the BCW was used to identify which interventions were utilised to address the barriers and enablers identified in Step 4. The COM-B analysis of documentation and app content (Table 2) was used to map the intervention functions Best Beginnings used in the Baby Buddy content. For example; having the knowledge of how to attach and position the baby for breastfeeding was a theme identified by Best Beginnings from the focus group data. This is related to having the physical capability, knowledge and skills (relevant TDF) and education, modelling and enablement (intervention functions). Breastfeeding video content mapped to the BCW (COM-B, TDF and intervention functions) is shown in Table 3.
Step 6 – The policy categories that were used
The outer layer of the BCW was used to analyse the app development process. This enabled the identification of policies, guidelines, fiscal measures, service provision, legislation, regulation, communication or environmental opportunities that were used to deliver the breastfeeding intervention and embed the app into the UK health service (24).
The Baby Buddy app was designed to complement maternity and postnatal services. It has been endorsed by the Department of Health, Faculty of Public Health and the Royal Colleges of: Paediatrics and Child Health; Obstetricians and Gynaecologists; Midwives; Psychiatrists and Speech and Language Therapists; as well as the Community Practitioners and Health Visitors Association and the Institute of Health Visiting. The content of Baby Buddy was co-created with parents and in consultation with stakeholders, for example, representatives from Royal Colleges and the Department of Health. No content is uploaded to Baby Buddy until representatives of all partners have given their approval.
Stage Three – Identifying how content and implementation choices were made
Step 7: How behaviour change techniques were used
Identification of BCTs was achieved by applying the BCTTv1 (Evaluation tool 3) to the content of the app. After each piece of content was categorised using the broad intervention categories, further analysis was carried out to identify exactly which BCTs were used (Table 3). These were then documented and specific examples and details given.
Step 8: Rationale for using Baby Buddy app as the mode of delivery
The APEASE criteria was used to evaluate if Best Beginnings had undertaken activities to ascertain acceptability, practicability, effectiveness, affordability, safety and equity (14). The evidence was analysed and judged against the previous DVD based breastfeeding intervention, ‘Bump to breastfeeding and the ‘Small Wonders’ DVD. In summary, Baby Buddy met the APEASE criteria for a viable digital intervention suitable for further testing, development and implementation (Additional file 2).
Market research was then undertaken to understand the need for an app in the context of other interventions that already existed in the UK. Workshops and focus groups conducted by Best Beginnings confirmed that there was a positive response from women to the concept of a mobile phone app. Positive factors of the app were thought to be; accessibility, everything in one place, fun and engaging, small ‘bite sized’ pieces of information, comprehensive and up-to-date information. Drivers to engage with the app were dependent on the age of the participants. Younger women, 15 to 18 years, were attracted to the fun elements of the app such as creating an avatar (Bump Buddy) and the gamification elements. Women over 18 years with a higher education level were more interested in the access to information a mobilie phone app might provide. Those who lacked access to healthcare or a personal network felt that the app would play both an informative and supportive role. Some of the younger women were concerned that they would not have access due to the type of phone they had or the additional cost.
Best Beginnings used a ‘person based approach’ to develop the look, feel and functionality of the app. Computer science was used to underpin the intervention development, such as; what was enjoyable, useful and also what the consumers wanted personalised. They also looked at the software in terms of decision support tools that could be used.
Breastfeeding content of the app is continually being revised and updated and has endorsement from several maternity health care experts and organisations. Maintaining credibility and sustainability of the app is heavily dependent on funding and participation of subject matter experts. This is led by a multi-disciplinary editorial board of the charity that reviews all changes to content within the app.
Best Beginnings used Kotter’s 8-Step process to guide implementation [17, 18]. This methodology, developed for change management involves an 8-Step process; 1) creating a sense of urgency, 2) building a guiding coalition, 3) forming a strategic vision and initiatives, 4) enlisting a volunteer army, 5) enabling action by removing barriers, 6) generating short-term wins, 7) sustaining acceleration and 8) instituting change (25, 26).
In terms of promotion, the app is approved by the several key organisations including PHE and the Royal College of Midwives (RCM). Public relations are utilised well and there has been significant media coverage. Promotion strategies are discussed regularly with the advisory group and stakeholders. The app is freely available on the Apple App Store and Google Play and recently been embedded into maternity and early years care pathways through the National Health Service (NHS) (21, 23, 27).